Report a Claim

Please be sure to contact your agent if filing a claim. Your agent is listed on your policy.

Please fill out this form to report a claim.

Today's Date

Name*

Policy Number

Agent

Cause of Loss

Contact Information

Address*

Street Address

City

State

Postal / Zip Code

At least one phone number must be provided.

Home Phone*

Cell Phone*

Business Phone*

Date of loss*

Location of loss*

Please describe loss:

Comments

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Fax: 515.992.4070

Tel: 515.992.4121

1410 Walnut St.

PO Box 624

Dallas Center, IA 50063

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